REFERENCE AUTORIZATION
I authorise (Company Name)______________________ to make an independent investigation of my background,
references, character, past employment and/or other records. I further agree that failure to reveal any prior
employment or the giving of any false or misleading information on this form will be grounds for termination of my
employment.
Signature ________________________________________________________________
Date Day_________ Month __________ Year____________
PLEASE PRINT:
Name _________________________________________ _____________________________________________
Last First Middle
Address _____________________________________________________________________________________( )______________________
Street City Province Postal Code Phone Number
__________________________________________________________________________________________________________________________
Date of Birth___________/_________/_____________
DAY MONTH YEAR
Were you ever employed by (Company Name)____________________ in the past? ________ if yes Dates:_____________________
State below names of 3 references:
Name Phone Number Company Name or Liaison From To
Give full particulars of your employment and/or time during the past ten years. If in school, give the name of the school and the dates
attended.
BEGIN WITH THE MOST RECENT POSITION
Date Name and Address of Previous Employer Manager Name Salary Reasons For Leaving
(From/To)
Are you presently employed with any other company, including part-time or self-employment?
YES _____ NO _____
If Yes, give:
Name of Company _______________________________ Position _______________________________________________
Address _______________________________________________________Phone # ( ) _________________________
